Tuesday, July 27, 2010

Outcomes? You Say You Want Outcomes?

The Journal of the American Medical Association (JAMA) can be forgiven for being physician-centric. So when it publishes an article on Medical Leadership in an Increasingly Complex World, the Disease Management Care Blog looks past the politics for the lessons. There's an important one here for not only physicians but, with some additional thought, all health organization leaders.

But are their collective sweat and tears misplaced? Author Robert Brook of Rand wonders if they may be. He notes physician leaders are ultimately using the patient-doc based "medical model" to build their empires. Without mentioning the disease/population health management industry by name, he also recognizes the growth of a second "public health"model ("driven primarily by the quest to eliminate root causes of population behavior that produces poor health"). However, there is also a third "social determinants of health" model that recognizes well being is also a function of income, safety and communities.

His point? Leaders must pursue all three models in balance. He thinks they should be regularly asking what they've done to advance the health of their communities in all three domains. He also thinks medical trainees and members of medical societies should be asking the same question. The DMCB adds the Boards and shareholders of publicly held companies offering care management services should be asking the same question also.

Long ago, while the DMCB was visiting a large health care institution, it asked what would happen to the mortality rate of the surrounding community if its bricks, mortar, equipment, employees, protocols, policies, physicians and nurses all vanished. Would the rate of obesity diminish? Would there be fewer premature births?

There was an uncomfortable silence. It's time to begin answering those simple questions.

5 comments:

I agree that the medical profession needs to recognize the "social determinants of health" model, and understand how exactly these determinants affect health directly and in interaction with public health / medical interventions.

That said, I think it's worth asking whether influencing these factors, especially through the public policy framework, is an appropriate goal for the medical profession.

It's perfectly logical to acknowledge that, for instance, obesity and poverty go hand in hand in part because of the lack of access to affordable healthful foods in some poorer neighbourhoods. It's fine to suggest that improving access to healthful foods in these areas would improve residents' health, and that vegetable subsidies or calorie taxes might achieve these results.

In my view, this is where medicine's role should end. Public policy should be driven by more than just health considerations. There are real tradeoffs between the health improvements that would arise from a soda tax, and the economic effects and even (dare I say) the "liberty" costs (to pick one example). This isn't to take a position on the policy, but simply to say that medical leaders should be cautious in doing so. That a policy will improve a certain population's health does not always make it the right one from a social point of view.

I think that approaching medicine from this viewpoint risks overmedicalizing some of these social problems. Perhaps they're best thought of as social problems with medical side effects, rather than as medical problems that require the intervention of physicians or physician-leaders.

Put another way, is there not a degree to which medicine should treat these social problems -- and social choices -- as exogenous constraints on health, as opposed to objects for medical influence and policy manipulation?

My thanks to DMCB for highlighting this excellent commentary. It makes me think the Hippocratic Oath (once again) needs updating: "I will do no harm and will advocate for societal policies that promote the health and wellbeing of my patients, even if they are adverse to my own personal gain."

Notwithstanding is not incoherent and, in my view, is quite correct in describing the limits of the medical profession's involvement in the third leg of health. The soda tax is a good example. Being reasonable and balanced makes a lot of sense.

Dear Jaan & Notwithstanding: You make your point, but not your case. What is wrong with, say, physicians advocating for a soda tax? Does personal freedom usurp all other consideration? Ahhh, then you must be strong advocates for abortion rights? But, back to soda and docs - a tax does not outlaw soda, but uses 'societal influence,' via the tax code, to express its mild disapproval. Its vehement disapproval would be expressed through an outright ban. Additionally, the revenues generated could be used to offset the public cost (i.e., Medicare, Medicaid, S-CHIP, ACA, cost-shifting, etc.) of the health consequence of soda in one's daily diet. Should not all health-conscious and public-treasury-conscious citizens be supportive of such a public policy, physicians notwithstanding? Of course, as fee-for-service servants, physicians could hide behind their medical hat and fattened bank accounts and say, as Jaan and Notwithstanding recommend, public health advocacy is "Not my yob, man."

There are two distinctions that I draw when considering physician/medical advocacy for/against interventions that have health effects.

The first is between purely medical and purely non-medical interventions, judged by the how/where/who of the intervention. There will obviously be grey areas, but let's set that aside for now. A purely medical intervention would be something like the often-cited central line infection prevention checklist, or A1C targets for disease management in diabetic patients. A purely non-medical intervention would be something like a soda tax or a Medicaid expansion. They obviously will have effects on health, but are not medical interventions per se.

The second distinction is between positive and normative advocacy. Positive advocacy illuminates aspects of a problem or a solution without endorsing a particular solution. Informing the public about the health effects and the public health / social determinants of obesity is positive advocacy. Publicizing the health effects of a soda tax, while arguably an area of research for economics researchers as opposed to physician-researchers, would be positive advocacy. Going from there to saying that a soda tax *should* be implemented is a leap into the normative realm.

What I'm wary of is normative advocacy for non-medical interventions that comes from medical organizations and physician leaders. By definition, these non-medical interventions occur via mechanisms and have side effects that are outside the typical purview, training, and expertise of the medical profession as a whole. Medical leadership should certainly play a role in the discussion by highlighting the health effects of these interventions, but crossing the line into normative advocacy is at best likely to be ill-informed at best, and irresponsible at worst.

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About Jaan Sidorov MD, MHSA, FACP

While his web persona has been described as a "blogvocateur," Dr. Sidorov has wide range of knowledge about the medical home, condition management, population-based health care and managed care that is only exceeded by his modesty. He has been quoted by the Wall Street Journal, Consumer Reports and NPR’s All Things Considered.
He has over 20 years experience in primary care, disease management and population based care coordination. He is a primary care general internist and former Medical Director at Geisinger Health Plan.
He is primary care by training, managed care by experience and population-based care strategies by disposition.
The contents of this blog reflect only the opinions of Sidorov and should not be interpreted to have anything to do with any current or past employers, clients, customers, friends, acquaintances or enemies, personal, professional, foreign or domestic. This is also not intended to function as medical advice. If you really need that, work with a personal physician or call 911 for crying out loud.
Jaan can be reached at jaansATaolDOTcom.